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Conner E, Gagrani M, Lalgudi VG, Shah PR, Hiasat J, Jhanji V, Nischal KK. Corneal Collagen Cross-linking for Keratoconus in Pediatric and Developmentally Delayed Patients. Cornea 2024:00003226-990000000-00589. [PMID: 39047195 DOI: 10.1097/ico.0000000000003562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/24/2024] [Indexed: 07/27/2024]
Abstract
PURPOSE Corneal cross-linking (CXL) is the standard of care in patients with keratoconus but presents unique challenges in children and developmentally delayed patients. We present our clinical decision-making algorithm, CXL surgical technique, and outcomes in these groups. METHODS A retrospective chart review was undertaken at a tertiary referral center of all patients who underwent CXL for keratoconus at University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh between October 1, 2017, and April 1, 2021. Demographic information along with preoperative, intraoperative, and postoperative ophthalmic examination findings were collected. The main outcome measures were indications of CXL, postoperative complications, and visual acuity (VA). RESULTS Forty-eight eyes of 34 patients [21 patients (30 eyes) with developmental delay (DD) and 13 patients (18 eyes) with no DD (NDD)] underwent epithelium-off, standard CXL. General anesthesia was used for CXL in all patients except for 3 with NDD. A temporary central tarsorrhaphy was performed in all patients with DD and 7 patients with NDD. The remaining got a bandage contact lens. There were no immediate postoperative complications. A trend toward improvement in VA was noted postoperatively. The mean logMAR VA (with habitual correction) was 0.67 preoperatively and 0.57 postoperatively (P = 0.3) in DD and 0.52 and 0.36, respectively (P = 0.13), in NDD. CONCLUSIONS This retrospective review presents a technique for assessment and treatment of keratoconus in children and those with DD. Our technique ensures timely diagnosis and provides a safe method for CXL in these groups. Temporary central tarsorrhaphy is a well-tolerated option to reduce postoperative pain.
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Affiliation(s)
- Elizabeth Conner
- Division of Pediatric Ophthalmology and Strabismus, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA. Dr. Conner is now with the Department of Ophthalmology, Christchurch Hospital, Christchurch, New Zealand and Dr. Shah is now with the Discipline Clinical Ophthalmology, The University of Sydney, Sydney, Australia
| | - Meghal Gagrani
- Division of Pediatric Ophthalmology and Strabismus, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA. Dr. Conner is now with the Department of Ophthalmology, Christchurch Hospital, Christchurch, New Zealand and Dr. Shah is now with the Discipline Clinical Ophthalmology, The University of Sydney, Sydney, Australia
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA; and
| | - Vaitheeswaran G Lalgudi
- Department of Ophthalmology, University at Buffalo, State University of New York, Buffalo, NY
| | - Parth R Shah
- Division of Pediatric Ophthalmology and Strabismus, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA. Dr. Conner is now with the Department of Ophthalmology, Christchurch Hospital, Christchurch, New Zealand and Dr. Shah is now with the Discipline Clinical Ophthalmology, The University of Sydney, Sydney, Australia
| | - Jamila Hiasat
- Division of Pediatric Ophthalmology and Strabismus, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA. Dr. Conner is now with the Department of Ophthalmology, Christchurch Hospital, Christchurch, New Zealand and Dr. Shah is now with the Discipline Clinical Ophthalmology, The University of Sydney, Sydney, Australia
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA; and
| | - Vishal Jhanji
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA; and
| | - Ken K Nischal
- Division of Pediatric Ophthalmology and Strabismus, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA. Dr. Conner is now with the Department of Ophthalmology, Christchurch Hospital, Christchurch, New Zealand and Dr. Shah is now with the Discipline Clinical Ophthalmology, The University of Sydney, Sydney, Australia
- Department of Ophthalmology, University at Buffalo, State University of New York, Buffalo, NY
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Albertazzi R, Rocha-de-Lossada C, Zaldivar R. A new technique to implant intracorneal ring-segments from the perilimbal region: one-year prospective pilot study report. BMC Ophthalmol 2024; 24:288. [PMID: 39014345 PMCID: PMC11251366 DOI: 10.1186/s12886-024-03552-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 07/01/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Recently a new surgical technique for intracorneal ring-segments (ICRS) assisted by femtosecond laser (FSL) called ByLimB was developed, involving the creation of the incision from a paralimbic region. This study aims to evaluate the safety and efficacy of the ByLimb technique following one year of follow-up. METHODS A prospective, single-center study was conducted at the Zaldivar Institute in Buenos Aires, Argentina. Keratoconus patients with indication for ICRS-FSL assisted procedure, operated with the ByLimb technique were included. By using the ByLimb technique, the ICRS are placed without affecting the tunnel's roof, and the end of the ICRS is always away from the incision area. Visual acuity, topographic astigmatism, and the occurrence of complications were evaluated. Safety index was the main outcome and efficacy indes was a complimentary outcome. RESULTS A total of 17 eyes completed the 12-month follow-up period. The safety index was 1.10 (mean postoperative corrected distance visual acuity (CDVA) in decimal: 0.76/preoperative CDVA: 0.69), while the efficacy index was 0.89 (mean postoperative uncorrected distance visual acuity UDVA in decimal: 0.62/preoperative CDVA: 0.69). Mean preoperative astigmatism was 5.3 ± 2.3, decreasing twelve months after surgery at 2.1 ± 1.2 (p < 0.001). No eye loss lines of vision and no intraoperative complications were observed. During the first month after surgery, an improper positioning of the ICRS based on topographic assessment was detected in five cases. A second procedure was performed, which consisted of opening the incision and introducing a Sinsky hook, through which the ICRS was mobilized and placed in its correct position. No incisional alterations, signs of infection, anterior segment anomalies, or fundus alterations were observed. CONCLUSION FSL-assisted ICRS implantation through the perilimbal region has demonstrated an adequate safety index one year post-surgery. Additionally, this technique has facilitated accurate realignment of ICRS during secondary surgical interventions within one-month post-surgery. While the current findings are promising, continued follow-up of these cases is warranted.
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Affiliation(s)
- Roberto Albertazzi
- Centro de Ojos Quilmes, Buenos Aires, 1865, Quilmes, Argentina.
- Instituto Zaldivar, Ciudad de Buenos Aires, 1865, Argentina.
| | - Carlos Rocha-de-Lossada
- Department of Ophthalmology, VITHAS Almería Hospital, Qvision, Almeria, 04120, Spain
- Department of Ophthalmology, Regional Universitary Hospital of Málaga, Granada, 18014, Spain
- Department of Surgery, Ophthalmology Area, University of Seville, Seville, 41012, Spain
- Department of Opthalmology, Vithas Malaga, Malaga, 29016, Spain
| | - Roger Zaldivar
- Instituto Zaldivar, Ciudad de Buenos Aires, 1865, Argentina
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Kirgiz A, Kemer Atik B, Emul M, Taskapili M. Clinical outcomes of femtosecond laser-assisted corneal allogenic intrastromal ring segment (CAIRS) in the treatment of keratoconus. Clin Exp Ophthalmol 2024. [PMID: 38938058 DOI: 10.1111/ceo.14411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 05/12/2024] [Accepted: 06/02/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND To evaluate the results of corneal allogenic intrastromal ring segment (CAIRS) implantation in keratoconus. METHODS The medical records of patients with keratoconus who underwent CAIRS implantation were reviewed. The CAIRS, prepared by trephination from the donor cornea, was implanted into a tunnel created using the femtosecond laser. The depth of the tunnel was 200 μ; the inner diameter of the tunnel was 4.5 mm; and the outer diameter was 7 mm. Uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), keratometry, minimum corneal thickness (CT), endothelial cell density (ECD), and high order aberration values were recorded preoperatively and at the 1st, 3rd, and 6th months postoperatively. RESULTS A total of 23 eyes of 23 patients were included in the study. Preoperative UCVA (0.08 ± 0.01) and BCVA (0.25 ± 0. 11) values improved postoperatively and reached 0.40 ± 0.05 and 0.68 ± 0.09, respectively, at the end of the 6-month follow-up period (p1 < 0.001, p2 = 0.016; respectively). A statistically significant flattening of all keratometric values was observed in the postoperative period compared to preoperatively (p < 0.001 for all). There were no statistical differences between CT and ECC values at the preoperative and postoperative visits (p1 = 0.654, p2 = 0.769; respectively). In addition, coma aberration values were lower than the preoperative values at all postoperative visits (p < 0.05 for all). CONCLUSIONS These results suggest that CAIRS implantation is a safe treatment option with good visual and keratometric outcomes for suitable patients with keratoconus.
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Affiliation(s)
- Ahmet Kirgiz
- Beyoglu Eye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Burcu Kemer Atik
- Beyoglu Eye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Merve Emul
- Beyoglu Eye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Muhittin Taskapili
- Beyoglu Eye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Keskin Perk FFN, Tanriverdi C, Karaca ZY, Tran KD, Kilic A. Long-Term Results of Sterile Corneal Allograft Ring Segments Implantation in Keratoconus Treatment. Cornea 2024:00003226-990000000-00581. [PMID: 38900741 DOI: 10.1097/ico.0000000000003592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/05/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE To evaluate the efficacy and safety of sterile corneal allograft ring segments implantation for the treatment of keratoconus by analyzing long-term visual, refractive, and tomographic clinical outcomes. METHODS This prospective study included 62 eyes of 49 patients with keratoconus who underwent corneal allograft ring segments implantation at Istanbul Medipol University Faculty of Medicine between February 2020 and August 2022. Surgical outcomes using the Istanbul nomogram were evaluated in patients preoperatively and postoperatively at 1 month, 6 months, 1 year, and 3 years. Outcomes measured were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent (SE), spherical refraction (SR), cylindrical refraction (CR), topographic keratometric values, and corneal thickness at the thinnest point. RESULTS Preoperative mean UDVA and CDVA (LogMAR) were 0.96 ± 0.50 and 0.72 ± 0.47, respectively, and increased to 0.41 ± 0.34 and 0.22 ± 0.19 at the last visit (P < 0.001). There was a significant decrease in SE, SR, and keratometric values postoperatively (P < 0.001). There was no difference in CR and thinnest corneal thickness values (P = 0.333 and 0.154, respectively). The stromal and epithelial thicknesses measured by anterior segment optical coherence tomography were stabilized at 6 months and 1 year, respectively. No major complications or side effects were observed intraoperatively or postoperatively. CONCLUSIONS This study demonstrated that sterile corneal allograft ring segments implantation is a safe and feasible treatment for keratoconus, yielding notable long-term visual outcomes with minimal implant-related complications.
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Affiliation(s)
| | - Cafer Tanriverdi
- Department of Ophthalmology, Istanbul Medipol University, Faculty of Medicine, Istanbul, Turkey
| | - Zeki Yigit Karaca
- Department of Ophthalmology, Istanbul Medipol University, Faculty of Medicine, Istanbul, Turkey
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Sara M, Hui A, Yasir M, Peguda HK, Kalaiselvan P, Willcox M. Intrastromal Corneal Ring Implants Associated Bacterial Infections. Curr Eye Res 2024:1-9. [PMID: 38780797 DOI: 10.1080/02713683.2024.2354438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE This study examines the incidence of infection and resistance associated with Intracorneal Ring Segment (ICRS) implantation, a common outpatient surgical treatment for correcting refractive errors and corneal ectatic diseases. Although ICRS procedures are typically safe and reversible, there is a low but notable risk of microbial infections, which require prompt and sometimes invasive treatment. METHODS Three electronic databases, PubMed, Web of Science (WoS), and Scopus, were utilised to search for literature according to PRISMA guidelines to identify infections related to the implantation of ICRS in the cornea between January 2000 and December 2022. RESULTS Gram-positive organisms were involved in 86% of cases: 35.7% S. aureus, 25% coagulase-negative staphylococci species, 17.8% streptococci and 7.1% Nocardia species. Less commonly recorded were Gram-negative bacteria (14%), with Pseudomonas aeruginosa (circa 10%) and Klebsiella pneumonia (4%) being the most common Gram-negative bacteria. In rare cases, fungi have also been reported. ICRS-related bacterial infections can be categorised into early or late onset. Early onset infection typically manifests within the first few weeks after implantation and is often associated with contamination during surgery, unhygienic practices, or inadequate sterilisation techniques. On the other hand, late-onset infection may develop months or even years after the initial procedures and may be associated with persistent bacterial colonisation, secondary infections, or prolonged use of prophylactic antibiotics. S aureus is encountered in both early and late-onset infections, while Nocardia species and K. pneumoniae have generally been reported to occur in late-onset infections. In addition, vision recovery from S. aureus infections tends to be poor compared to other bacterial infections. CONCLUSION S. aureus is a predominant pathogen that often requires surgical intervention with poor outcomes. Early infections result from incision gaps and ring segment rubbing, while late infections are linked to prolonged antibiotic use. Further research is needed on novel antimicrobial ICRS to procure the vision.
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Affiliation(s)
- Manjulatha Sara
- School of Optometry and Vision Science, UNSW Sydney, Sydney, New South Wales, Australia
| | - Alex Hui
- School of Optometry and Vision Science, UNSW Sydney, Sydney, New South Wales, Australia
- Centre for Ocular Research and Education, University of Waterloo, Waterloo, Ontario, Canada
| | - Muhammad Yasir
- School of Optometry and Vision Science, UNSW Sydney, Sydney, New South Wales, Australia
| | - Hari Kumar Peguda
- School of Optometry and Vision Science, UNSW Sydney, Sydney, New South Wales, Australia
| | | | - Mark Willcox
- School of Optometry and Vision Science, UNSW Sydney, Sydney, New South Wales, Australia
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Vega A, Alió JL. Criteria for patient selection and indication for intracorneal ring segments in keratoconus. EYE AND VISION (LONDON, ENGLAND) 2024; 11:13. [PMID: 38528633 PMCID: PMC10964652 DOI: 10.1186/s40662-024-00379-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 02/23/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Keratoconus is an ectatic, progressive corneal disorder characterized by alterations in the morphology of the corneal tissue that leads to limitation of visual function of the patient. Intracorneal ring segments (ICRS) are small synthetic devices that are implanted in the corneal stromal in order to regularize the morphology of the tissue therefore improving the visual function and the quality of life of the patients. MAIN TEXT The present narrative review summarizes the main scientific articles developed by the authors in relation to the clinical outcomes and long-term results of ICRS in the treatment of keratoconus. It was found that those patients that benefit the most from this surgical intervention are those that have the most severe form of keratoconus. Additionally, patients with good visual function, those with more than 0.9 in the decimal scale are at risk of losing visual acuity after ICRS implantation. In relation to long-term results, scientific investigations published by the authors demonstrate that ICRS is a stable procedure after long period of time in terms of vision, refraction, and topographic variables in those patients with stable keratoconus. However, in patients with keratoconus and signs of progression, ICRS may not have the capability of halting the progression of the disease. Using artificial intelligence to guide ICRS implantation provide better clinical outcomes and improvement in corneal higher-order aberrations in patients with keratoconus in comparison to those treated using the commercial nomogram of implantation. CONCLUSIONS ICRS is a safe surgical procedure in the treatment of keratoconus. Patients that benefit most from the surgery are those with a significant visual impairment. ICRS should not be considered in patients with good visual function because of the risk of losing lines of vision. Long-term follow-up demonstrate stability of the clinical outcomes in patients with stable keratoconus although ICRS may not have the ability of halting the progression of the disease. New technologies based artificial intelligence improved the indications and the clinical outcomes of keratoconus patients treated with ICRS.
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Affiliation(s)
- Alfredo Vega
- Grupo Miranza, Alicante, Spain
- Universidad Miguel Hernandez de Elche, Alicante, Spain
- Hospital Virgen de los Lirios de Alcoy, Alicante, Spain
| | - Jorge L Alió
- Grupo Miranza, Alicante, Spain.
- Universidad Miguel Hernandez de Elche, Alicante, Spain.
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D'Oria F, Bagaglia SA, Alio Del Barrio JL, Alessio G, Alio JL, Mazzotta C. Refractive surgical correction and treatment of keratoconus. Surv Ophthalmol 2024; 69:122-139. [PMID: 37774800 DOI: 10.1016/j.survophthal.2023.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023]
Abstract
Keratoconus is an ectatic corneal disorder that causes severe vision loss. Surgical options allow us to correct, partially or totally, the induced refractive error. Intracorneal ring segments (ICRS) implantation represents a minimally invasive surgical option that improves visual acuity, with a high success rate and a low overall complication rate. Corneal allogenic ICRS consists of ring segments derived from allogenic eye bank-processed donor corneas. Selective topography-guided transepithelial photorefractive or phototherapeutic keratectomy combined with CXL is another way in selected cases to improve spectacles corrected distance visual acuity. The microphotoablative remodeling of the central corneal profile is generally planned by optimizing the optical zones and minimizing tissue consumption. Phakic intraocular lens (PIOL) implant is considered in patients with stable disease and acceptable anatomical requirements. The two types of pIOLs, depending on their implantation inside the eye, are anterior chamber-pIOLs, which fixate to the anterior surface of the iris by using a polymethomethacrolate claw at the two haptics, and posterior chamber-pIOLs. In patients with both cataracts and keratoconus, the correct IOL power is difficult to obtain due to the irregular corneal shape and K values. Toric IOL is recommended, but carefully judging the topography and the possible need of subsequent keratoplasties.
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Affiliation(s)
- Francesco D'Oria
- Section of Ophthalmology, Department of Basic Medical Science, Neuroscience and Sense Organs, University of Bari, Bari, Italy.
| | - Simone A Bagaglia
- Departmental Ophthalmology Unit, Sant' Andrea Hospital, USL Toscana Sud-Est, Massa Marittima, Italy
| | - Jorge L Alio Del Barrio
- Vissum Miranza, Alicante, Spain; Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain
| | - Giovanni Alessio
- Section of Ophthalmology, Department of Basic Medical Science, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Jorge L Alio
- Vissum Miranza, Alicante, Spain; Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain.
| | - Cosimo Mazzotta
- Departmental Ophthalmology Unit, AUSL Toscana Sud Est, Campostaggia, Siena, Italy; Department of Medicine, Surgery and Neurosciences, Postgraduate Ophthalmology School, Siena University, Siena, Italy; Siena Crosslinking Center, Siena, Italy
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Jacob S, Agarwal A, Awwad ST, Mazzotta C, Parashar P, Jambulingam S. Customized corneal allogenic intrastromal ring segments (CAIRS) for keratoconus with decentered asymmetric cone. Indian J Ophthalmol 2023; 71:3723-3729. [PMID: 37991313 PMCID: PMC10788746 DOI: 10.4103/ijo.ijo_1988_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023] Open
Abstract
Corneal allogenic intrastromal ring segments (CAIRS) refer to the intracorneal placement of fresh, unprocessed, processed, preserved, or packaged allogenic rings/segments of any type/length. We described uniform-thickness CAIRS previously. We now describe a new technique of customized CAIRS to personalize the flattening effect as per individual topography. A prospective interventional case series of patients with pericentral/ paracentral decentered cones and gradation of keratometry with one side steeper than the other was conducted. Individually customized tapered CAIRS with variable volume, arc length, taper length, and gradient of taper were implanted. In total, 32 eyes of 29 patients with at least 1-year follow-up were included. Special double-bladed trephines and a CAIRS customizer template allowed the creation of individually customized CAIRS. Mean uncorrected distance visual acuity (UDVA) and spectacle-corrected distance visual acuity improved from 0.22 to 0.47 (P = 0.000) and from 0.76 to 0.89 (P = 0.001), respectively. Significant improvement was seen in K1, K2, Km, Kmax, topographic astigmatism, Q-value, sphere, cylinder, spherical equivalent, Root Mean Square (RMS), Higher Order Aberrations (HOA), and vertical coma (P < 0.01, 0.05). There was no significant change in the width or height of CAIRS between 1 month and last visit on anterior-segment optical coherence tomography. Five eyes continued to remain at the same UDVA, 27 eyes had at least 2 lines, and 13 eyes had at least 3 or more lines improvement in UDVA. The maximum improvement in UDVA was 7 lines. A significant difference in flattening was obtained at different zones across the tapered CAIRS. Thus, differential flattening was achieved across the cone based on the customization plan. Personalized customization was possible for each cornea, unlike limited models of progressive-thickness synthetic segments. Allogenic nature, greater customizability, efficacy, and absent need for large inventories are advantages compared to synthetic segments.
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Affiliation(s)
- Soosan Jacob
- Department of Cornea, Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, Tamil Nadu, India
- Department of Cornea, Dr. Agarwal's Refractive and Cornea Foundation, Chennai, Tamil Nadu, India
| | - Amar Agarwal
- Department of Cornea, Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, Tamil Nadu, India
| | - Shady T Awwad
- Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Cosimo Mazzotta
- Departmental Ophthalmology Unit, Alta Val D'elsa Hospital, USL Toscana Sudest, Italy
- Siena Crosslinking Center, Italy
| | - Parnika Parashar
- Department of Cornea, Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, Tamil Nadu, India
- Department of Cornea, Dr. Agarwal's Refractive and Cornea Foundation, Chennai, Tamil Nadu, India
| | - Sambath Jambulingam
- Department of Cornea, Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, Tamil Nadu, India
- Department of Cornea, Dr. Agarwal's Refractive and Cornea Foundation, Chennai, Tamil Nadu, India
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Nacaroglu SA, Yesilkaya EC, Perk FFNK, Tanriverdi C, Taneri S, Kilic A. Efficacy and safety of intracorneal allogenic ring segment implantation in keratoconus: 1-year results. Eye (Lond) 2023; 37:3807-3812. [PMID: 37328510 PMCID: PMC10698022 DOI: 10.1038/s41433-023-02618-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 05/15/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND To evaluate the safety and efficacy of corneal allogenic intrastromal ring segments in the management of keratoconus patients. METHODS The retrospective, nonrandomized, interventional case series consisted of 65 keratoconic eyes of 49 consecutive patients who had ring segment-shaped corneal allografts (KeraNatural®) implanted in intrastromal tunnels created using a femtosecond laser. The main outcome measures were uncorrected visual acuity (UCVA), corrected distant visual acuity (CDVA), refraction, keratometry, and pachymetry. Computed tomography scans of the corneal surfaces were also performed preoperatively as well as 3, 6 and 12 months postoperatively. RESULTS Mean age was 29.5 ± 7.3 years (median 29, range: 20-52 years). The mean UCVA improved from 0.91 ± 0.50 logMAR preoperatively to 0.40 ± 0.24 logMAR postoperatively at 6 month follow-up (p < 0.01) and the mean CDVA improved from 0.87 ± 0.20 logMAR preoperatively to 0.27 ± 0.06 logMAR postoperatively (p < 0.01). The mean spherical equivalent improved from -8.82 ± 4.57 to -3.45 ± 4.81D (p < 0.01). Average Keratometry decreased from 49.23 ± 5.22 preoperatively to 45.63 ± 4.89 D postoperatively (p < 0.01). Mean anterior and posterior maximum elevation were also decreased significantly (p < 0.01). In one patient, dislocation of the graft towards the tunnel incision site and dehiscense at the tunnel entrance were observed in the first week of the operation. Yellow-white deposits were observed in the segment tunnels in five cases after 6 months. CONCLUSION This study demonstrated that implantation of corneal allograft ring segments is a viable alternative treatment for keratoconus with safety and good visual results.
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Affiliation(s)
- Senay Asik Nacaroglu
- Faculty of Medicine, Ophthalmology Department, Istanbul Medipol University, Istanbul, Turkey.
| | - Elif Ceren Yesilkaya
- Şişli Hamidiye Etfal Training and Research Hospital, Department of Ophthalmology, University of Health Sciences, Istanbul, Turkey
| | | | - Cafer Tanriverdi
- Faculty of Medicine, Ophthalmology Department, Istanbul Medipol University, Istanbul, Turkey
| | - Suphi Taneri
- Ophthalmology Department, Augenzentrum am St. Franziskus Hospital, Munster, Germany
| | - Aylin Kilic
- Faculty of Medicine, Ophthalmology Department, Istanbul Medipol University, Istanbul, Turkey
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10
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Albertazzi R, Rocha-de-Lossada C, Perrone LD, Valvecchia G, Perrone F, Ferlini L, Taboada D, Roude AL. Late-onset distal-apical intracorneal ring-segments keratopathy: an analysis of a large sample in a multicenter study. Int Ophthalmol 2023; 43:3923-3933. [PMID: 37531002 DOI: 10.1007/s10792-023-02793-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/22/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE To review the prevalence and describe the characteristics, of cases with late-onset intracorneal ring segments (ICRS) keratopathy in a multicenter study. METHODS A retrospective multicentric case-series study was performed in a specialized keratoconus service, from Buenos Aires, Argentina. An electronic clinical chart from patients with ICRS keratopathy between January 1999 and January 2019 was reviewed. We included cases with late-onset distal-apical ICRS keratopathy, which was defined as a persistent corneal lesion developed 12 months or later after implantation, located over, around, or closer to the ICRS. All the surgeries were performed by a manual corneal tunnel creation technique. Samples were taken to rule out infectious etiology. RESULTS From 5217 eyes that underwent ICRS implantation, 13 cases (0.24%) were detected. The keratopathy onset was 72 ± 42.98 months (29-133) after ICRS implantation. Cultures were negative in all cases. An ICRS exchange was made for five cases in stage I and four in stage II. Four cases presented with partial ICRS extrusion in stage III. ICRS exchange was possible in two of them and a penetration keratoplasty was necessary for the rest. All cases remained stable 1 year after surgical procedures. CONCLUSIONS A late-onset distal-apical ICRS keratopathy was detected with low prevalence (0.24%) in a large sample. It was classified into three stages according to its severity. Different treatments were selected for each stage, obtaining stable results 1 year after treatment.
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Affiliation(s)
- Roberto Albertazzi
- Centro de Ojos Quilmes (Keratoconus Service), Humberto Primo, 298, 1878, Quilmes, Buenos Aires, Argentina.
| | - Carlos Rocha-de-Lossada
- Qvision-Vithas, Almeria; Vithas Málaga (Department of Ophthalmology; Spain), Almería, Spain
- Department of Ophthalmology, Regional University Hospital of Málaga; Department of Surgery, Ophthalmology, Universidad de Sevilla, Málaga, Spain
| | - Luciano D Perrone
- Centro de Ojos Quilmes (Keratoconus Service), Humberto Primo, 298, 1878, Quilmes, Buenos Aires, Argentina
| | - Gerardo Valvecchia
- Centro de Ojos Quilmes (Keratoconus Service), Humberto Primo, 298, 1878, Quilmes, Buenos Aires, Argentina
| | - Franco Perrone
- Centro de Ojos Quilmes (Keratoconus Service), Humberto Primo, 298, 1878, Quilmes, Buenos Aires, Argentina
| | - Leonardo Ferlini
- Centro de Ojos Quilmes (Keratoconus Service), Humberto Primo, 298, 1878, Quilmes, Buenos Aires, Argentina
| | - Delfina Taboada
- Centro de Ojos Quilmes (Keratoconus Service), Humberto Primo, 298, 1878, Quilmes, Buenos Aires, Argentina
| | - Alfredo L Roude
- Clínica de Ojos Nano (Cornea Service), Olivos, Buenos Aires, Argentina
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11
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Neves Cruz C, Franqueira N, Mendes JC, Oliveira M, Monteiro T. Intrastromal corneal ring segments: effect of depth of implantation in visual, refractive, and topographic outcomes in patients with keratoconus. J Cataract Refract Surg 2023; 49:949-955. [PMID: 37379026 DOI: 10.1097/j.jcrs.0000000000001249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/21/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE To evaluate visual, refractive, and topographic outcomes of intracorneal ring segment implantation in relation to the achieved segment depth, using the manual technique. SETTING Ophthalmology Department, Hospital de Braga, Braga, Portugal. DESIGN Retrospective cohort study. METHODS We obtained 104 eyes of 93 patients with keratoconus submitted to Ferrara intracorneal ring segment (ICRS) implantation, using a manual technique. Subjects were divided into 3 groups according to the achieved depth of implantation: 40% to 70% (Group 1), 70% to 80% (Group 2), and 80% to 100% (Group 3). Visual, refractive, and topographic variables were evaluated at baseline and 6 months. Topographic measurement was performed using Pentacam. Thibos-Horner and Alpins methods were used to analyze the vectorial change of refractive and topographic astigmatism, respectively. RESULTS We found a significant improvement of uncorrected distance visual acuity and corrected distance visual acuity in all groups at 6 months ( P < .005); no differences were observed regarding safety and efficacy indexes in the 3 groups ( P > .05). Manifest cylinder and spherical equivalent significantly reduced in all groups ( P < .05). Topographic evaluation showed a significant improvement of all parameters in the 3 groups ( P < .05). A shallower (Group 1) or deeper (Group 3) implantation was associated with topographic cylinder overcorrection, a higher magnitude of error, and a higher mean centroid postoperative corneal astigmatism. CONCLUSIONS ICRS implantation with the manual technique showed to be equally effective in visual and refractive outcomes despite the depth of implantation; however, shallower or deeper implants were associated with topographic overcorrection and a higher mean centroid postoperative astigmatism, which explain the lower topographic predictability associated with manual surgery for ICRS implantation.
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Affiliation(s)
- Carlos Neves Cruz
- From the Ophthalmology Department, Hospital de Braga, Braga, Portugal (Cruz, Franqueira, Mendes, Oliveira, Monteiro); Escola de Medicina da Universidade do Minho, Braga, Portugal (Monteiro)
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12
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Deshmukh R, Ong ZZ, Rampat R, Alió del Barrio JL, Barua A, Ang M, Mehta JS, Said DG, Dua HS, Ambrósio R, Ting DSJ. Management of keratoconus: an updated review. Front Med (Lausanne) 2023; 10:1212314. [PMID: 37409272 PMCID: PMC10318194 DOI: 10.3389/fmed.2023.1212314] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
Keratoconus is the most common corneal ectatic disorder. It is characterized by progressive corneal thinning with resultant irregular astigmatism and myopia. Its prevalence has been estimated at 1:375 to 1:2,000 people globally, with a considerably higher rate in the younger populations. Over the past two decades, there was a paradigm shift in the management of keratoconus. The treatment has expanded significantly from conservative management (e.g., spectacles and contact lenses wear) and penetrating keratoplasty to many other therapeutic and refractive modalities, including corneal cross-linking (with various protocols/techniques), combined CXL-keratorefractive surgeries, intracorneal ring segments, anterior lamellar keratoplasty, and more recently, Bowman's layer transplantation, stromal keratophakia, and stromal regeneration. Several recent large genome-wide association studies (GWAS) have identified important genetic mutations relevant to keratoconus, facilitating the development of potential gene therapy targeting keratoconus and halting the disease progression. In addition, attempts have been made to leverage the power of artificial intelligence-assisted algorithms in enabling earlier detection and progression prediction in keratoconus. In this review, we provide a comprehensive overview of the current and emerging treatment of keratoconus and propose a treatment algorithm for systematically guiding the management of this common clinical entity.
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Affiliation(s)
- Rashmi Deshmukh
- Department of Cornea and Refractive Surgery, LV Prasad Eye Institute, Hyderabad, India
| | - Zun Zheng Ong
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
| | - Radhika Rampat
- Department of Ophthalmology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Jorge L. Alió del Barrio
- Cornea, Cataract and Refractive Surgery Unit, Vissum (Miranza Group), Alicante, Spain
- Division of Ophthalmology, School of Medicine, Universidad Miguel Hernández, Alicante, Spain
| | - Ankur Barua
- Birmingham and Midland Eye Centre, Birmingham, United Kingdom
| | - Marcus Ang
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Jodhbir S. Mehta
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Dalia G. Said
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Harminder S. Dua
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Renato Ambrósio
- Department of Cornea and Refractive Surgery, Instituto de Olhos Renato Ambrósio, Rio de Janeiro, Brazil
- Department of Ophthalmology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
- Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Darren Shu Jeng Ting
- Birmingham and Midland Eye Centre, Birmingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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13
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Albertazzi R, Zaldivar R, Rocha-de-Lossada C. ByLimb: Development of a New Technique to Implant Intracorneal Ring-Segments from the Perilimbal Region. Life (Basel) 2023; 13:1283. [PMID: 37374066 DOI: 10.3390/life13061283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/11/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
A new technique that allows implanting intracorneal ring-segments (ICRS) from the limbal zone is described. Using a femtosecond laser (FSL), a 360° corneal tunnel is created with an internal diameter of 5.4 mm and an external diameter of 7.0 mm, with a wider area (0.2 mm inner and 0.2 mm outer) in the upper 60° of the tunnel (called landing zone). Next, a 4.36 mm-long corneal-limbal incision was created with the FSL, which connects to the bubbles created in the landing zone. The entire procedure was performed using intraoperative optical coherence tomography (OCT). Once the two incisions were connected using blunt-edged Mac Pherson forceps, the bubbles were released from the surgical plane. The programmed ICRS(s), 6 mm in diameter, are then placed in the corneal tunnel from the limbal incision with the aid of Sinskey forceps. Finally, when the ICRS is in place, the surgery is complete.
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Affiliation(s)
- Roberto Albertazzi
- Centro de Ojos Quilmes, Quilmes 1865, Argentina
- Instituto Zaldivar, Ciudad de Buenos Aires 1865, Argentina
| | - Roger Zaldivar
- Instituto Zaldivar, Ciudad de Buenos Aires 1865, Argentina
| | - Carlos Rocha-de-Lossada
- Department of Ophthalmology, Qvision, VITHAS Almería Hospital, 04120 Almeria, Spain
- Department of Ophthalmology, Regional Universitary Hospital of Málaga, 18014 Granada, Spain
- Department of Surgery, Ophthalmology Area, University of Seville, 41012 Seville, Spain
- Department of Opthalmology, Vithas Malaga, 29016 Malaga, Spain
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14
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Kozhaya K, Mehanna CJ, Jacob S, Saad A, Jabbur NS, Awwad ST. Management of Anterior Stromal Necrosis After Polymethylmethacrylate ICRS: Explantation Versus Exchange With Corneal Allogenic Intrastromal Ring Segments. J Refract Surg 2022; 38:256-263. [PMID: 35412922 DOI: 10.3928/1081597x-20220223-01] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate management of keratoconic eyes with anterior stromal necrosis overlying the intracorneal ring segment (ICRS), by either ICRS explantation alone or exchange with corneal allogenic intrastromal ring segments (CAIRS). METHODS Among 643 Intacs SK (Additional Technology, Inc) inserted at one institutional center, 16 eyes (15 patients) with overlying spontaneous anterior stromal necrosis were identified. Data included size of stromal defect and refractive and topographical findings before ICRS insertion, before anterior stromal necrosis, and 6 months after intervention. RESULTS The 10-year incidence of anterior stromal necrosis after femtosecond laser-assisted ICRS insertion was 5.5%. Eight eyes underwent ICRS removal only and 8 eyes had ICRS exchanged with CAIRS. In the first group, CDVA worsened from 0.14 before melt to 0.28 logMAR after removal (P = .10), simulated keratometry (SimK) and maximum axial keratometry (Kmax) increased from 44.73 to 46.34 diopters (D) (P = .14) and from 49.23 to 52.26 D (P = .14), respectively, and coma worsened from 0.87 to 1.52 D (P = .02). In the CAIRS group, CDVA of 0.16 before melt improved to 0.11 logMAR postoperatively (P > .99), and topographic indices stabilized with SimK, Kmax, and coma mildly altering from 45.31 to 45.44 D (P > .99), from 49.25 to 49.64 D (P > .99) and from 0.87 to 0.81 D (P > .99), respectively. Whether the ICRS were explanted or exchanged, the visual and topographic mean values were better than those reported before ICRS implantation, whereas higher order aberrations in eyes without CAIRS regressed to levels before ICRS insertion. At the site of melt, thinnest residual stromal thickness averaged 327 µm with ICRS removal and 490 µm with CAIRS. Eyes with larger melt areas resulted in less optimal results with CAIRS implantation. CONCLUSIONS Early experience in the management of anterior stromal necrosis by exchange of polymethylmethacrylate ICRS with CAIRS seems to avoid stromal thinning and confer better visual and topographic results, which were more pronounced with thicker segments. The benefit of CAIRS in large stromal melts needs to be investigated. [J Refract Surg. 2022;38(4):256-263.].
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15
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Hamon L, Schlötzer-Schrehardt U, Flockerzi FA, Seitz B, Daas L. Morphological characterization and clinical effects of stromal alterations after intracorneal ring segment implantation in keratoconus. Graefes Arch Clin Exp Ophthalmol 2022; 260:2299-2308. [PMID: 35106630 PMCID: PMC9203383 DOI: 10.1007/s00417-022-05572-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To analyze the histological and (ultra)structural stromal tissue changes after femtosecond (Fs) laser-assisted intracorneal ring segment (ICRS) implantation and their refractive and topographic effects in patients with keratoconus. METHODS This monocentric retrospective case series included 15 consecutive patients with clinical peri-segmental lamellar channel deposits after treatment with Fs-ICRS implantation for keratoconus. The stromal changes were investigated using in vivo confocal microscopy. Two patients underwent a penetrating keratoplasty after the Fs-ICRS implantation; the explanted corneas were processed for histopathology and transmission electron microscopy (TEM). Refractive and topographic effects were investigated comparing the uncorrected (UDVA) and corrected (CDVA) distance visual acuity, spherical equivalent (SE), flat (K1), steep (K2), and steepest (Kmax) keratometry before and after detection of lamellar channel deposits. RESULTS In vivo confocal microscopy revealed diffuse linear and focal granular hyperreflective structures. Histologically, there was mild proliferation of fibroblasts and fibrosis. TEM demonstrated focal accumulations of degenerated keratocytes with cytoplasmic lipid inclusions. There were no significant changes for UDVA (Δ = 0.0 ± 0.2 logMAR; p = 0.67), CDVA (Δ = 0.0 ± 0.1 logMAR; p = 0.32), SE (Δ 0.1 ± 0.9 D; p = 0.22), K1 (Δ = 0.3 ± 1.0 D; p = 0.28), K2 (Δ = 0.1 ± 0.9 D; p = 0.51), and Kmax (Δ = 0.3 ± 1.5 D; p = 0.17). CONCLUSIONS Two types of structural stromal changes were identified: (1) diffuse peri-segmental fibrosis and (2) lamellar channel deposits. These structural changes showed no evidence of a relevant refractive or topographic effect.
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Affiliation(s)
- Loïc Hamon
- Department of Ophthalmology, Saarland University Medical Center (UKS), Kirrberger Straße 100, Bld. 22, 66421 Homburg, Saar Germany
| | - Ursula Schlötzer-Schrehardt
- Department of Ophthalmology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Fidelis A. Flockerzi
- Department of Pathology, Saarland University Medical Center (UKS), Homburg, Saar Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center (UKS), Kirrberger Straße 100, Bld. 22, 66421 Homburg, Saar Germany
| | - Loay Daas
- Department of Ophthalmology, Saarland University Medical Center (UKS), Kirrberger Straße 100, Bld. 22, 66421 Homburg, Saar Germany
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16
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Jafarinasab MR, Hadi Y, Espandar G. Femtosecond Laser-assisted Allogenic Additive Stromal Keratoplasty With or Without Excimer Laser Donor Keratomileusis for Management of Keratoconus. J Ophthalmic Vis Res 2021; 16:691-697. [PMID: 34840692 PMCID: PMC8593540 DOI: 10.18502/jovr.v16i4.9761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 06/26/2021] [Indexed: 12/02/2022] Open
Abstract
We describe a modified allogenic intrastromal lenticule implantation technique for management of keratoconus (KCN). Patients with advanced KCN already scheduled for corneal transplantation were enrolled. An allogenic corneal lenticule was implanted inside a stromal pocket created by femtosecond laser. In three cases, the estimated refractive error of the recipient eyes was corrected on the donor lenticules using an Excimer laser. All operated eyes underwent corneal crosslinking at the time of surgery. This method was named “Femtosecond Laser-assisted Allogenic Stromal Keratoplasty Without and With Excimer Laser-assisted Donor Keratomileusis”; briefly called FASK and FASK Plus EDK, respectively. Two out of five patients were satisfied with the results. There was a decrease in the average simulated keratometric values as well as myopia when FASK Plus EDK was performed. Increased corneal thickness was achieved in all cases. Graft edema gradually decreased over weeks but interface wrinkling and lenticule folds in the visual axis remained as a problem during follow-up period. No other complications were encountered.
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Affiliation(s)
- Mohammad-Reza Jafarinasab
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yasaman Hadi
- Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Goldis Espandar
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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17
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Femtosecond Laser and Mechanical Dissection for ICRS and MyoRing Implantation: A Meta-Analysis. Cornea 2021; 41:518-537. [PMID: 34839335 DOI: 10.1097/ico.0000000000002937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/01/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The aims of this meta-analysis were to evaluate the results of intracorneal ring segments (ICRSs) and MyoRing in the management of corneal ectasia and to compare the clinical outcomes and complication rates between mechanical and femtosecond (FS) laser-assisted surgery. METHODS An online electronic search was performed for pre-post studies published until April 2020. Uncorrected distance visual acuity, corrected distance visual acuity, sphere, cylinder, spherical equivalent, steep, flat, and mean keratometry values were considered as outcomes. Weighted mean difference with 95% confidence interval was used as a pooled estimation of intervention efficacy. RESULTS Of 1484 potentially related studies, 115 studies were finally included in the meta-analysis. Findings of this meta-analysis demonstrated considerable improvement in visual, refractive, and keratometric outcomes in all ICRS models and MyoRing. Intrastromal tunnel creation with both methods yielded similar results. Complication rates were without exception higher when mechanical dissection was used. CONCLUSIONS ICRS and MyoRing are appropriate treatment options for patients with corneal ectasia. Both techniques for tunnel creation are efficacious in achieving good visual, keratometric, and refractive results. Mechanical intrastromal tunnel creation is associated with much higher complication rates when compared with FS laser-assisted technique.
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18
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Hamon L, Seitz B, Daas L. Intrastromal fibrosis and lipid deposits twenty years after intracorneal ring segments implantation for treatment of mild myopia. J Fr Ophtalmol 2021; 45:147-150. [PMID: 34802752 DOI: 10.1016/j.jfo.2021.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/25/2021] [Accepted: 06/04/2021] [Indexed: 10/19/2022]
Affiliation(s)
- L Hamon
- Centre Hospitalier Universitaire de la Sarre (UKS), Homburg/Saar, Germany.
| | - B Seitz
- Centre Hospitalier Universitaire de la Sarre (UKS), Homburg/Saar, Germany
| | - L Daas
- Centre Hospitalier Universitaire de la Sarre (UKS), Homburg/Saar, Germany
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19
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Moshirfar M, Milner DC, Martheswaran T, McCabe SE, Ronquillo YC, Hoopes PC. Delayed Perforation of an Intrastromal Corneal Ring Segment into the Anterior Chamber: A Case Report and Review of the Literature. Case Rep Ophthalmol 2021; 12:740-748. [PMID: 34720972 PMCID: PMC8460883 DOI: 10.1159/000518012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/20/2021] [Indexed: 11/19/2022] Open
Abstract
Intrastromal corneal ring segments (ICRSs) are an effective treatment for stabilizing and normalizing corneal shape in patients with keratoconus and other corneal ectasias. Intraoperative segment perforation through the corneal endothelium into the anterior chamber (AC) is an uncommon but known complication. However, perforation into the AC postoperatively is an exceedingly rare complication with only 3 reported cases in the literature. One case was due to Descemet membrane detachment and another due to ocular trauma. In the third case, the mechanism for perforation was unclear. We present the fourth case of delayed ICRS perforation due to silent migration through the endothelium into the AC. We also present all reported cases in the literature of intraoperative and postoperative perforation into the AC.
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Affiliation(s)
- Majid Moshirfar
- Hoopes Vision Research Center, Hoopes Vision, Draper, Utah, USA.,John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Utah Lions Eye Bank, Murray, Utah, USA
| | - Dallin C Milner
- University of Colorado School of Medicine, Aurora, Colorado, USA
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20
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Comment on: Five-year long-term outcomes of intrastromal corneal ring segment implantation using the manual technique. J Cataract Refract Surg 2021; 47:1494-1495. [PMID: 34675163 DOI: 10.1097/j.jcrs.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Jafarinasab M, Hadi Y. Femtosecond laser-assisted peripheral additive stromal keratoplasty for treatment of primary corneal ectasia: Preliminary outcomes. Indian J Ophthalmol 2021; 69:2663-2668. [PMID: 34571610 PMCID: PMC8597526 DOI: 10.4103/ijo.ijo_3206_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Purpose: To report the preliminary results of a new surgical modality for the treatment of primary corneal ectasia, which consists of implanting allogeneic corneal tissue into the peripheral corneal stroma using a femtosecond laser system or femtosecond laser-assisted peripheral allogeneic stromal additive keratoplasty or FA-PASAK. Methods: This prospective, noncomparative case series includes patients with primary corneal ectasia including keratoconus and pellucid marginal degeneration. In the operating room, one or two ring or crescent-shaped allogeneic corneal segments were prepared using a handmade double-bladed punch, which were then implanted by a specially designed device, into stromal channels in the peripheral recipient cornea fashioned with a femtosecond-laser system. Results: A total of 15 eyes of 13 patients with mean age of 31.73 years were operated. There were significant improvements in uncorrected (0.68 to 0.3 logMAR) and corrected (0.44 to 0.16 logMAR) visual acuity, mean sphere, mean spherical equivalent refractive error, and mean keratometry (steep, flat, and average). Topographic and refractive astigmatism did not change significantly. Complications included a single case of bacterial keratitis secondary to epithelial defect, which was controlled with topical antibiotics eventually leading to an uncorrected vision of 20/25 one year after surgery. Conclusion: The use of allogeneic corneal ring or crescent shape segments may be a safe and cost-effective treatment for primary corneal ectasia, whereas a nomogram is necessary to be devised for general use of the technique.
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Affiliation(s)
- Mohammadreza Jafarinasab
- Eye Research Center, Shahid Labbafi Nejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yasaman Hadi
- Eye Research Center, Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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22
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Anders P, Anders LM, Elalfy M, Hamada S, Seitz B, Gatzioufas Z. Effect of intracorneal ring segment implantation on high order aberrations comparing patients with eccentric versus central keratoconus. Eur J Ophthalmol 2021; 32:36-42. [PMID: 34405714 DOI: 10.1177/11206721211041022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To assess potential differences between central and eccentric cones in the aberrometric corneal profile and in visual and keratometric outcomes 6 months after intracorneal ring segment (ICRS) implantation for keratoconus. METHODS This study compared two groups consisting of 12 patients each, with central or eccentric keratoconus who were treated with femtosecond laser-assisted Keraring implantation. Uncorrected (UDVA) and corrected (CDVA) distance visual acuity, keratometric readings and higher order aberrations (HOAs) including high order aberrations root mean square (HOARMS), coma, spherical aberration and trefoil were measured preoperatively and 6 months after ICRS implantation. RESULTS Trefoil and spherical aberration were significantly reduced after ICRS implantation compared to preoperative values in eccentric keratoconus (Trefoil, p = 0.0049; Spherical aberration, p < 0.0001). In central keratoconus spherical aberration was reduced not significantly after ICRS implantation compared to preoperative values (p = 0.087). Coma showed a significant reduction in central (p = 0.0001) and in eccentric keratoconus (p = 0.0001). The reduction of spherical aberration in central keratoconus was significantly positively correlated to improvement in UDVA (Pearson's correlation coefficient, r = -0.66; p = 0.02). In eccentric keratoconus there was a significant positive correlation between reduction of trefoil and improvement in UDVA (Spearmans R, r = -0.69; p = 0.01). CONCLUSION Patients both with central and eccentric keratoconus benefit from ICRS implantation. Specifically, our data provide a slightly higher gain in visual performance for eccentric cones 6 month after ICRS implantation, which is accentuated by a greater reduction in spherical aberration and trefoil. Improvements in UDVA are positively correlated with reductions in HOAs.
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Affiliation(s)
- Philipp Anders
- Institute of Molecular and Clinical Ophthalmology Basel, Basel, Switzerland.,Department of Ophthalmology, University of Basel, Basel, Switzerland
| | - Lisa-Marie Anders
- Institute of Molecular and Clinical Ophthalmology Basel, Basel, Switzerland.,Department of Ophthalmology, University of Basel, Basel, Switzerland
| | - Mohamed Elalfy
- Corneo-Plastic Unit, Queen Victoria Hospital, East Grinstead, West Sussex, UK
| | - Samer Hamada
- Corneo-Plastic Unit, Queen Victoria Hospital, East Grinstead, West Sussex, UK
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center, Homburg, Saar, Germany
| | - Zisis Gatzioufas
- Institute of Molecular and Clinical Ophthalmology Basel, Basel, Switzerland.,Department of Ophthalmology, University of Basel, Basel, Switzerland
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Astigmatic Change as a Predictor of Intrastromal Corneal Ring Segment Late Extrusion. J Cataract Refract Surg 2021; 48:401-407. [PMID: 34393182 DOI: 10.1097/j.jcrs.0000000000000774] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 08/06/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate changes in keratoconic corneas implanted with intracorneal ring segments (ICRS) that have been explanted due to late extrusion of the segment after >2 years. SETTING Vissum Miranza, Alicante, Spain; OftalmoSalud, Lima, Peru; Minya University Hospital, Egypt. METHODS Retrospective, multicenter, series of cases of 23 keratoconic corneas that have been implanted for > 2 years and have been explanted due to natural extrusion of the segment. Clinical measures of visual, refractive, topographic, pachymetric and aberrometric data were analyzed. To perform exploratory factor analysis, the Kaiser-Meyer-Olkin (KMO) test was used to evaluate sampling adequacy. Factor analysis with VARIMAX rotation was used to determine the main factors of the inventory. RESULTS Mean time interval 5 years. Topographic findings were reversed nearly to the baseline level after segment explantation (p>0.05). Significant worsened in refractive cylinder was found pre-ICRS extrusion (p<0.05). KMO revealed a suitability of 0.528 in the preimplantation matrix (p<.001), 0.534 in the postimplantation matrix (p<.001), 0.549 in the preexplantation matrix (p=.009). Main factor obtained in the preimplantation moment included keratoconus grade, keratometric readings and visual acuities. After ICRS implantation, the most strength components were the refractive cylinder, CDVA and UDVA. Corneal aberrations were the main factors in the preexplantation analysis. CONCLUSIONS ICRS can be safely extracted, with a reversal of the corneal topographic data to the preoperative level. We showed a significant astigmatic change in patients implanted with ICRS before late extrusion of the segment, suggesting the role of this parameter as a prognostic factor of extrusion.
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David C, Kallel S, Trinh L, Goemaere I, Borderie V, Bouheraoua N. [Intracorneal ring segments in keratoconus management]. J Fr Ophtalmol 2021; 44:882-898. [PMID: 33895029 DOI: 10.1016/j.jfo.2020.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 11/25/2022]
Abstract
Intracorneal ring segments (ICRS), used in the management of keratoconus since the 2000s, have enjoyed significant technological development. Various types of ICRS exist, whose arc length, thickness, and diameter can be chosen according to the desired effect on the spherical equivalent, keratometry and asphericity. Individualized implantation strategies, based on each patient's topographic and tomographic pattern, are constantly evolving. The surgical procedure is standardized, and complications remain very rare. Combined procedures (corneal collagen cross-linking and refractive photokeratectomy±topo-guided, phakic and pseudophakic intraocular lenses) are increasingly used and require a good knowledge of the effect of ICRS alone on the keratoconic cornea. The objective of this review is to summarize clinical practices used in the visual rehabilitation of keratoconic patients using the ICRS+- combined procedures.
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Affiliation(s)
- C David
- INSERM-DGOS CIC 1423, CHNO des Quinze-Vingts, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France
| | - S Kallel
- INSERM-DGOS CIC 1423, CHNO des Quinze-Vingts, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France
| | - L Trinh
- INSERM-DGOS CIC 1423, CHNO des Quinze-Vingts, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France
| | - I Goemaere
- INSERM-DGOS CIC 1423, CHNO des Quinze-Vingts, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France
| | - V Borderie
- INSERM-DGOS CIC 1423, CHNO des Quinze-Vingts, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France; Inserm, CNRS, Sorbonne université, institut de la Vision, 17, rue Moreau, 75012 Paris, France
| | - N Bouheraoua
- INSERM-DGOS CIC 1423, CHNO des Quinze-Vingts, IHU ForeSight, 28, rue de Charenton, 75012 Paris, France; Inserm, CNRS, Sorbonne université, institut de la Vision, 17, rue Moreau, 75012 Paris, France.
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Ormonde S. Refractive surgery for keratoconus. Clin Exp Optom 2021; 96:173-82. [DOI: 10.1111/cxo.12051] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 01/31/2013] [Accepted: 02/03/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- Sue Ormonde
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand,
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Sinjab MM, Rubinfeld RS, Wagner K, Parsons Jnr EC, Cummings AB, Belin MW. Outcomes of Conductive Keratoplasty Combined with Corneal Crosslinking in Advanced Ectatic Corneal Disease. Clin Ophthalmol 2021; 15:1317-1329. [PMID: 33824576 PMCID: PMC8018415 DOI: 10.2147/opth.s259012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 01/15/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the effectiveness of a novel treatment for patients with advanced corneal ectasia and loss of visual acuity (VA). Conductive keratoplasty (CK) is performed to improve VA followed by epithelium-on (epi-on) corneal crosslinking (CXL) to stabilize the cornea after CK. Methods Retrospective, exploratory cohort study. Patients with keratoconus or postsurgical ectasia and best spectacle-corrected distance VA (CDVA) ≤ 20/40 were included. Conductive keratoplasty was performed (ViewPoint CK System, Refractec, Inc., Bloomington, MN); followed a day later by epi-on CXL (CXLUSA/CXLO, Bethesda, MD/CXLO Encinitas, CA). Measures included uncorrected distance visual acuity (UDVA) and CDVA, as well as refractive and tomographic measures and tomographic indices. Results Data from 50 eyes of 45 patients were analyzed. Mean follow-up was 15.1 ± 12.2 months (range: 2 to 51). Overall, UDVA and CDVA improved postoperatively. Subjective refraction and tomographic metrics did not show consistent changes, but changes in tomographic indices were associated with treatment follow-up time. At the 1-year visit, mean UDVA significantly improved over baseline (P = 0.009) by approximately 3 lines; mean CDVA improved significantly (P = 10−5) by approximately 2 lines. No eye lost lines of CDVA. Change in the Index of Surface Variance (ISV) was associated with treatment, and the D-Index trended over follow-up time. Conclusion Conductive keratoplasty with a proprietary epi-on CXL treatment improved vision in patients with advanced ectasia This CK/epi-on CXL treatment offers the possibility of improved VA for patients with compromised vision due to ectasia.
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Affiliation(s)
- Mazen M Sinjab
- Dr. Mazen Eye Clinic, Medcare Hospitals and Centres, Dubai, United Arab Emirates.,Al Zahra Medical Group, Damascus, Syria
| | - Roy S Rubinfeld
- Department of Ophthalmology, Georgetown University Medical School/Washington Hospital Center, Washington, DC, USA.,Re:Vision Private Practice, Rockville, MD, USA
| | - Kirsten Wagner
- Department of Ophthalmology, Medstar Georgetown University Hospital, Washington, DC, USA.,Department of Ophthalmology, Medstar Washington Hospital Center, Washington, DC, USA
| | | | | | - Michael W Belin
- Department of Ophthalmology, University of Arizona, Tucson, AZ, USA
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Jabbarvand M, Khodaparast M, Jamali A, Ahmadzadeh H, Bordbar S. Changes in the Optical Corneal Densitometry, Visual Acuity, and Refractive Error after the Annular Intracorneal Inlay Implantation. J Curr Ophthalmol 2021; 33:23-30. [PMID: 34084953 PMCID: PMC8102947 DOI: 10.4103/joco.joco_154_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/04/2020] [Accepted: 09/29/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose: To investigate the changes in the optical corneal densitometry as an objective method in assessing the corneal light back-scattering before and 1 year after the annular intracorneal inlay (AICI) implantation into the keratoconic corneas. Methods: Changes in the optical corneal densitometry, visual acuity, refractive, and tomographical status were assessed before and 1 year after the AICI implantation into the corneas with different stages of keratoconus. Optical corneal densitometry was evaluated using the Pentacam-HR in 0–2, 2–6, 6–10, and 10–12 mm rings in the anterior 120 μ, central layers, posterior 60 μ and also the total value were measured for cornea in the Grey Scale Unit criterion. Results: Totally, 34 patients with keratoconus were studied; the uncorrected and best corrected visual acuity were increased after the surgery (0.98 ± 0.25 to 0.53 ± 0.30 logMAR, P < 0.001 and 0.26 ± 0.18 to 0.19 ± 0.14, P = 0.007 logMAR, respectively); the spherical equivalent was decreased from −4.45 ± 2.25 to − 2.06 ± 2.01 D (P = 0.004). AICI implantation led to an increase in the amount of optical corneal densitometry in 0–2 mm central, 2–6 mm central, 6–10 mm central, total central, 2–6 mm posterior, and 2–6 mm total rings (all, P < 0.05); however, a decrease was observed in 0–2 mm anterior ring (P = 0.049). Results of statistical analysis showed that the total optical corneal densitometry, anterior total, and posterior total back-scattering did not change after the AICI implantation (all, P > 0.05). Conclusions: Our results revealed a significant improvement in the visual function, including refractive error and visual acuity following the AICI implantation. Changes in the optical corneal densitometry were different in distinct regions and layers however, the total amount did not change after the AICI implantation.
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Affiliation(s)
- Mahmoud Jabbarvand
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Khodaparast
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Jamali
- Rehabilitation Research Center, Department of Optometry, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hooman Ahmadzadeh
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Soodeh Bordbar
- English Department, Iran University of Medical Sciences, Tehran, Iran
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Femtosecond laser-assisted stromal keratophakia for keratoconus: A systemic review and meta-analysis. Int Ophthalmol 2021; 41:1965-1979. [PMID: 33609200 DOI: 10.1007/s10792-021-01745-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 02/06/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Femtosecond lasers have revived the possibility of stromal keratophakia or tissue additive keratoplasty, a technique originally introduced by Prof. Jose Ignacio Barraquer in the 1960s. The surgical technique offers a unique solution to treat keratoconus. In the current study, we reviewed and performed a meta-analysis of the clinical outcomes of the femtosecond laser-assisted stromal keratophakia in the treatment of keratoconus. METHODS This is a systematic review and meta-analysis of the estimated outcome difference between pre- and post-lenticule implantations. RESULTS A total of related 10 studies were found in the literature. No studies reported adverse events, such as persistent haze or graft rejection, at last patients' visits. We further narrowed down the article selection in accordance to our inclusion criteria to report the composite outcomes (9 studies) and meta-analysis (4 studies). In the composite analysis, we demonstrated that lenticule implantation in keratoconus and post-LASIK ectasia patients appeared to expand the stromal volume of the thin corneas, flattened the cones, and significantly improved uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA) and spherical equivalent (SE). The meta-analysis showed that the random estimated UCVA, BCVA, SE and mean keratometry (Km) differences following the lenticule implantation was -0.214 (95% CI: -0.367 to 0.060; p = 0.006), -0.169 (-0.246 to 0.091; p < 0.001), -2.294 D (-3.750 to -0.839 D; p = 0.002), and 2.909 D (0.805 to 5.012 D; p = 0.007), respectively. CONCLUSIONS Femtosecond laser-assisted stromal keratophakia is a feasible technique to correct the refractive aberrations, expand corneal volume and regularize corneal curvature in patients with keratoconus. However, there is a need to standardize the technique (e.g., whether to crosslink or not or to use convex or concave lenticules) and to formulate a mathematical model that accounts for the long-term epithelial thickness changes and stromal remodeling to determine the shape or profile of the lenticules, in order to improve the efficacy of the keratophakia further.
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D'Oria F, Abdelghany AA, Ledo N, Barraquer RI, Alio JL. Incidence and Reasons for Intrastromal Corneal Ring Segment Explantation. Am J Ophthalmol 2021; 222:351-358. [PMID: 33011155 DOI: 10.1016/j.ajo.2020.09.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE To determine the main causes of intrastromal corneal ring segment (ICRS) explantation and define the incidence rate. DESIGN Multicenter, observational consecutive case series. METHODS Consecutive cases of ICRSs explanted in the last 10 years were reviewed. Clinical data included age of the patients at explantation, reasons for implantation and explantation, date of implantation and explantation, tunnel creation technique, and ICRS type. Main outcomes measures were the reasons for ICRS removal and the incidence rate. RESULTS During the study period, 121 ICRSs (119 patients) were explanted, with an explantation rate of 5.60%. Functional failure (74 eyes, 61.16%) represents the main cause for ICRS removal: of them, 48 (39.67%) ICRSs were removed for refractive failure and 26 (21.49%) in the setting of a keratoplasty related to poor visual performance of the implanted eye. In addition, 47 eyes (38.84%) had ICRS removal for anatomic failure: among them, 36 (29.75%) were explanted for spontaneous extrusion (overall extrusion rate: 1.58%), 7 (5.79%) for suspected infectious keratitis, 3 (2.48%) for corneal melting, and 1 (0.83%) for corneal perforation. Mild cases of keratoconus were more prone to be explanted because of a loss of the initial improved visual acuity, whereas spontaneous extrusion happened often in advanced cases of keratoconus. CONCLUSIONS We report the largest series of ICRS explantation as of this writing. The main cause of explantation was functional refractive failure followed by spontaneous extrusion of the ICRS, that is, correlated to an anatomic failure at the site of implantation in an advanced disease.
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Affiliation(s)
- Francesco D'Oria
- Vissum Innovation, Alicante, Spain; Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain; Section of Ophthalmology, Department of Basic Medical Science, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Ahmed A Abdelghany
- Vissum Innovation, Alicante, Spain; Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain; Ophthalmology department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Natalia Ledo
- Instituto Universitario Barraquer, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rafael I Barraquer
- Instituto Universitario Barraquer, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jorge L Alio
- Vissum Innovation, Alicante, Spain; Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain.
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Sedaghat MR, Momeni-Moghaddam H, Belin MW, Piñero DP, Akbarzadeh R, Ambrósio R, Hosseini SR. Comparative analysis of two different types of intracorneal implants in keratoconus: A corneal tomographic study. Eur J Ophthalmol 2020; 31:1517-1524. [PMID: 33124461 DOI: 10.1177/1120672120963449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate changes in visual acuity and corneal tomographic outcomes at 6 months after femtosecond-laser assisted implantation of two different types of intracorneal implants in keratoconus. METHODS A total of 39 keratoconus eyes implanted with two segments KeraRing (n = 22 eyes) or MyoRing (n = 17 eyes) were enrolled. Tomographic data (Pentacam system, Oculus) were analyzed and correlated with enhancement in uncorrected (UDVA) and corrected distance visual acuity (CDVA). The tomographic indices were front maximum keratometry (Kmax), corneal asphericity (Q-value) on both surfaces, average pachymetric progression indices (PPI), maximum Ambrosio relational thickness (ARTmax), Belin-Ambrósio enhanced ectasia total deviation index (BAD-D), index of surface variance (ISV), vertical asymmetry (IVA), height asymmetry (IHA) and height decentration (IHD). RESULTS LogMAR UDVA and CDVA improved 2.1 (p = 0.003) and 0.7 (p = 0.074) lines with KeraRing, and 8 and 2.5 lines with MyoRing (p = 0.001). The highest and lowest mean differences in the tomographic indices between both groups were related to ISV and IHD, respectively. Changes in all indices differed significantly between two groups except for changes in front corneal astigmatism, ARTmax, ISV, IVA, IHD and IHA (p > 0.05). Correlation of changes in CDVA with changes in other parameters was statistically significant only for IHD in the KeraRing group, while changes in in UDVA were significantly correlated with changes in spherical equivalent, back Q-value, ISV, IVA, and IHA only in the MyoRing group. CONCLUSION Both implants promote corneal shape regularization and an enhancement in UDVA in keratoconus. A considerable flattening effect and reduction in prolateness in the front corneal surface were observed with MyoRing.
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Affiliation(s)
| | - Hamed Momeni-Moghaddam
- Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran.,Department of Optometry, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Michael W Belin
- Department of Ophthalmology & Vision Science, University of Arizona, Tucson, AZ, USA
| | - David P Piñero
- Department of Optics, Pharmacology and Anatomy, University of Alicante, Alicante, Spain
| | - Reyhaneh Akbarzadeh
- Department of Optometry, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Renato Ambrósio
- Department of Ophthalmology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Seyed Rafi Hosseini
- Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
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Eliaçık M, Kırgız A, Tülü Aygün B. Evaluation of corneal thickness with spectral-domain optical coherence tomography following keraring implantation for keratoconus: five year follow-up. Curr Eye Res 2020; 45:1359-1363. [PMID: 32228114 DOI: 10.1080/02713683.2020.1749667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
To evaluate the change in the position of intrastromal corneal ring segments (ICRS) implanted in keratoconus patients within five years of implantation. Participants in this study included keratoconus patients who received Keraring 10 ICRS implantation and had a follow-up time of at least 5 years. The distances from apex to anterior corneal surface (AA), from outer basal corner to posterior corneal surface (BP), and from inner basal corner to posterior corneal surface (CP) were measured at every postoperative visit (6 months, 1 year, 3 years, and 5 years) and compared to each other. Thirty eyes of 22 patients were included. The CP showed a statistically significant decrease at all 15 time points (p < .001); however, no statistically significant difference was found at 5 years regarding AA or BP (p > .05 for all). Triangular ICRS implanted in keratoconus patients remained stable for five years without any complications, which is an extremely important aspect of ICRS surgery. The only difference was a slight posterior movement of the inner basal corner, although without anterior chamber perforation.
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Affiliation(s)
- Mustafa Eliaçık
- School of Medicine, Department of Ophthalmology, Medipol University , Istanbul, Turkey
| | - Ahmet Kırgız
- Ophthalmology Department, Beyoglu Eye Training and Research Hospital, University of Health Sciences , Istanbul, Turkey
| | - Beril Tülü Aygün
- Ophthalmology Department, Beyoglu Eye Training and Research Hospital, University of Health Sciences , Istanbul, Turkey
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Extrusion of Femtosecond Laser-Implanted Intrastromal Corneal Ring Segments in Keratoconic Eyes: Prevalence, Risk Factors, and Clinical Outcomes. J Ophthalmol 2020; 2020:8704219. [PMID: 32318286 PMCID: PMC7152975 DOI: 10.1155/2020/8704219] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/07/2020] [Accepted: 03/10/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose To evaluate the prevalence, possible risk factors, and clinical results of femtosecond laser implanted intrastromal corneal ring segment (ICRS) extrusion in keratoconic eyes. Patients and Methods. This is a retrospective observational study evaluating 333 eyes of 269 patients who were subjected to femtosecond laser-implanted Keraring ICRS in the Sohag Refractive Center, Sohag, Egypt, from January 2014 to January 2019. The study included eyes with channels created by a femtosecond laser (60 kHz IntraLase femtosecond system; Advanced Medical Optics, Santa Ana, California, USA) with implantation of Keraring intrastromal corneal ring segments (Mediphacos, Belo Horizonte, Brazil). Patient data and causes of Keraring extrusions were identified as being those rings that migrated or showed melting of the cornea with no other reason which required segment removal. Results Seven eyes were found to fit the criteria of ring extrusion (2.1%) out of the 333 eyes which had Keraring implantation. All extruded rings were from patients with keratoconus grade 3, with eccentric cones, and with femtosecond creation of the tunnel. Four eyes belonging to 3 patients (57.1%) had a history of vernal Keratoconjunctivitis, yet they did not show signs of activity at the time of implantation. They reported excessive rubbing just before they presented with conjunctival hyperemia and foreign body sensation. Five eyes (71.4%) showed chronic sun exposure. The mean minimal corneal thickness was 401.85 μm (range 384–420 μm), while the mean maximum keratometry was 61 D (range 55.18–68.96 D). Most of the extruded rings had large arcs. Six eyes had crosslinking (CXL) at the same session of the Keraring implantation. The simultaneous CXL treatment is considered as a possible significant risk factor for ring extrusion. Conclusion ICRS is an effective reversible option for patients with keratoconus who are intolerant to hard contact lenses, yet the choice of cases and ring segments is mandatory for satisfactory results. Moreover, meticulous history taking and examination reduces the incidence of complications including extrusion.
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Agarwal P, Subudhi P, Mithal N. Novel technique of fixing intracorneal rings segments after migration. BMJ Case Rep 2020; 13:13/1/e233312. [PMID: 31948976 DOI: 10.1136/bcr-2019-233312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 38-year-old patient with a history of non-progressive keratoconus in the left eye presented to us with an uncorrected visual acuity of 20/400, which improved to 20/60 with pinhole. We planned for intracorneal rings segment in the left eye. Postoperatively uncorrected visual acuity improved to 20/30. The patient presented 2 weeks later with severely decreased vision to 20/100 and migration of intracorneal rings were noted with both the rings riding side by side. The patient gave history of vigorous eye rubbing. The rings were repositioned with the help of Sinskey hooks and superior ring was anchored with 10-nylon suture passed through the ring hole to the corneal stroma. Two more sutures were placed radial to the circumference of inferior ring to prevent its migration. The sutures were removed after 1 month and the patient was followed up with stable position of the rings for the next 6 months . The uncorrected visual acuity improved to 20/40.
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Affiliation(s)
- Prateek Agarwal
- Eye Institute, Cleveland Clinic Abudhabi, Abu Dhabi, United Arab Emirates
| | - Praveen Subudhi
- Ophthalmology, Ruby Eye Hospital, Berhampur, India.,Ophthalmology, KIMS, Bhubaneswar, India
| | - Neha Mithal
- Ophthalmology, AlAhaliya Eye Care Center, Abu Dhabi, United Arab Emirates
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Kanellopoulos AJ, Vingopoulos F. Combining Porcine Xenograft Intra-Corneal Ring Segments and CXL: a Novel Technique. Clin Ophthalmol 2020; 13:2521-2525. [PMID: 31908406 PMCID: PMC6925549 DOI: 10.2147/opth.s230011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/05/2019] [Indexed: 12/05/2022] Open
Abstract
Purpose The ex-vivo feasibility of creating corneal ring segments (ICRS) from biological tissue (xenograft porcine cornea) and combining intra-corneal implantation with Corneal CrossLinking (CXL). Methods The ring segments from gamma-irradiated porcine donor cornea were shaped and implanted in human cadaver host cornea using a femtosecond laser for their dissection and host cornea channel preparation. Intra-channel 0.25% riboflavin solution combined with higher fluence CXL of 15 joules total energy followed their implantation. Anterior segment Optical Coherence Tomography (OCT), Scheimpflug tomography and Placido-disc topography were used to monitor the positioning and refractive effect. Results The novel xenograft ring segments were positioned as planned at 85% corneal depth and mid-peripheral, with documented, up to 7 diopters central cornea flattening. Conclusion Xenograft intracorneal ring segments combined with CXL may offer an alternative to the synthetic materials used clinically so far, aiming in reducing complications of intracorneal opaque deposit accumulation, segment migration, corneal erosion and potential extrusion. Combining CXL may enhance their refractive effect and stabilize potential or documented host ectasia. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/goEJP2fKfgs
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Affiliation(s)
- Anastasios John Kanellopoulos
- Department of Ophthalmology, LaserVision Clinical & Research Eye Institute, Athens, Greece.,Department of Ophthalmology, New York University Medical School, New York, NY, USA
| | - Filippos Vingopoulos
- Department of Ophthalmology, LaserVision Clinical & Research Eye Institute, Athens, Greece
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Bautista-Llamas MJ, Sánchez-González MC, López-Izquierdo I, López-Muñoz A, Gargallo-Martínez B, De-Hita-Cantalejo C, Sánchez-González JM. Complications and Explantation Reasons in Intracorneal Ring Segments (ICRS) Implantation: A Systematic Review. J Refract Surg 2019; 35:740-747. [DOI: 10.3928/1081597x-20191010-02] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/10/2019] [Indexed: 11/20/2022]
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Femtosecond Laser Implantation of a 355-Degree Intrastromal Corneal Ring Segment in Keratoconus: A Three-Year Follow-Up. J Ophthalmol 2019; 2019:6783181. [PMID: 31687200 PMCID: PMC6803737 DOI: 10.1155/2019/6783181] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 09/04/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose To evaluate the outcomes of femtosecond laser-assisted implantation of a 355-degree intracorneal ring (ICR) (Keraring) in patients with keratoconus in the three-year follow-up. Setting Future Femtolaser Center, Sohag, Egypt. Design Prospective interventional case series. Patients and Methods A prospective case series of 38 eyes of 26 patients with keratoconus had implantation of the 355-degree ICR keraring after tunnel creation with a femtosecond laser. The uncorrected visual acuities (UCVA) and best-corrected visual acuities (BCVA), sphere, cylinder, and manifest refraction spherical equivalent (SE), and mean keratometry (K), K max, and K min were evaluated preoperatively and 3, 6, 12, 24, and 36 months postoperatively, and all complications were reported. Results 38 eyes of 26 patients with mean age 25.92 ± 5.44 years were enrolled in the study, 11 were males (42.3%). The mean UCVA improved from 0.93 ± 0.21 to 0.63 ± 0.21 logMAR (P ≤ 0.001) and the mean BCVA from 0.67 ± 0.22 to 0.43 ± 0.26 logMAR (P < 0.001). The mean sphere, cylinder, and spherical equivalent have been changed dramatically from preoperative to 3 month postoperative, which is statistically significant (P ≤ 0.001), and the changes between 1 and 2 years and 2 and 3 years are also considerable and statistically significant; the K max and K min and K mean improved and the changes were statistically significant (P ≤ 0.001), and the changes between one, two, and three years were also statistically significant. The safety and efficacy indices were changed through the three-year follow-up. The complications were corneal neovascularization (36.84%), corneal melting (26.3%), and ring extrusion (31.5%) at the end of the study. Conclusions Implantation of a 355-degree intracorneal keraring using femtosecond laser improved the visual, refractive, and topographic parameters in keratoconus patients, with a high rate of ICR extrusion and instability. The study has been registered for the Pan African Clinical Trial Registry (http://www.pactr.org) database within No: PACTR201810796878908 on 29 October 2018.
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Sakellaris D, Balidis M, Gorou O, Szentmary N, Alexoudis A, Grieshaber MC, Sagri D, Scholl H, Gatzioufas Z. Intracorneal Ring Segment Implantation in the Management of Keratoconus: An Evidence-Based Approach. Ophthalmol Ther 2019; 8:5-14. [PMID: 31605316 PMCID: PMC6789055 DOI: 10.1007/s40123-019-00211-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Indexed: 01/19/2023] Open
Abstract
Intracorneal ring segment (ICRS) implantation represents a modern, minimally invasive, surgical option for visual improvement in patients with keratoconus. ICRS modify the corneal geometry in a manner that enhances its refractive properties and thereby, they improve visual acuity. It is well-documented that implantation of ICRS decreases the keratometric readings, spherical equivalent and cylinder, reduces high-order aberrations and improves uncorrected distance visual acuity (UDVA) and best-corrected distance visual acuity (BCDVA) in patients with keratoconus. Success rate after ICRS implantation is high, depending on appropriate patient selection and adherence to suitable implantation nomograms, and most important, the overall complication rate is very low. This review is summarizing current indications/contra-indications for ICRS implantation, implantation techniques, clinical outcomes and potential complications, shedding light on myths and realities related to this innovative surgical option.
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Affiliation(s)
| | | | - Olga Gorou
- Ophthalmica Institute, Thessaloniki, Greece
| | - Nora Szentmary
- Department of Ophthalmology, University Clinic Saarland, Homburg, Saarland, Germany
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - Antonios Alexoudis
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | | | | | - Hendrik Scholl
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - Zisis Gatzioufas
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland.
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Biologic stromal ring to manage stromal melting after intrastromal corneal ring segment implantation. J Cataract Refract Surg 2019; 45:1222-1225. [PMID: 31371149 DOI: 10.1016/j.jcrs.2019.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/30/2019] [Accepted: 05/16/2019] [Indexed: 11/23/2022]
Abstract
We report a new technique to replace a manufactured poly(methyl methacrylate) (PMMA) ring with a biologic stromal ring fashioned from human corneal donor tissue in eyes with stromal melting above the PMMA ring. The biologic stromal ring is prepared using manual or femtosecond laser trephination of a donor cornea to obtain a 360-degree ring that is denuded and adjusted to match the PMMA ring being replaced. The biologic ring is attached to the PMMA ring. The PMMA ring is pushed and retrieved from the other side, which installs the biologic ring in place. Six biologic stromal rings were implanted successfully in 5 eyes of 5 patients with previous stromal melting; no complications were reported up to 6 months postoperatively. The biologic stromal ring stopped and healed the melting, prevented further ring complications, and preserved the therapeutic refractive effect of the previously implanted PMMA ring.
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Koh IH, Seo KY, Park SB, Yang H, Kim I, Kim JS, Hwang DG, Nam SM. One-Year Efficacy and Safety of Combined Photorefractive Keratectomy and Accelerated Corneal Collagen Cross-Linking after Intacs SK Intracorneal Ring Segment Implantation in Moderate Keratoconus. BIOMED RESEARCH INTERNATIONAL 2019; 2019:7850216. [PMID: 31360724 PMCID: PMC6644267 DOI: 10.1155/2019/7850216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 06/24/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE To report one-year outcomes of a modified version of two-stage multimodal surgical protocol for moderate keratoconus which has been suggesting promising preliminary results. MATERIALS AND METHODS 30 eyes of 25 patients with moderate keratoconus who exhibited visual complaints and/or disease progression were included for this retrospective case study. Approximately 3 months after implantation of intracorneal ring segment (Intacs SK™), a combination of corneal wavefront-guided transepithelial photorefractive keratectomy (CWG-transPRK, Schwind Amaris® 1050, and Schwind Sirius) and accelerated collagen cross-linking (accCXL, Avedro KXL™) was performed. Patients were examined for uncorrected and corrected distance visual acuity (UDVA; CDVA), keratometric power (K), corneal thickness, and corneal higher-order aberrations (HOAs) preoperatively and at postoperative 1, 3, 6, and 12 months. RESULTS The median UDVA and mean CDVA were enhanced from 6/38 to 6/12 and from 6/19 to 6/7.5, respectively, through 12 months after CWG-transPRK/accCXL. The 12-month CDVA of all patients was better than 6/12 Snellen, and no subject lost one or more lines of CDVA. The magnitudes of both myopia and corneal steepness were decreased in turn by Intacs SK implantation and also by CWG-transPRK/accCXL, but the reduction in HOA was largely the result of CWG-transPRK/accCXL. The magnitude of corneal thinning stabilized within 3 months after CWG-transPRK/accCXL. CONCLUSION This approach may allow patients with moderate keratoconus to obtain satisfactory vision without the need for contact lens wear. This surgery appeared to be effective and safe through 1 year of follow-up.
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Affiliation(s)
- Il Hwan Koh
- SU Yonsei Eye Clinic, Seoul, Republic of Korea
| | - Kyoung Yul Seo
- Department of Ophthalmology, Institute of Vision Research, Eye and Ear Hospital, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | - Hun Yang
- SU Yonsei Eye Clinic, Seoul, Republic of Korea
| | - InSik Kim
- SU Yonsei Eye Clinic, Seoul, Republic of Korea
| | - Jin Sun Kim
- SU Yonsei Eye Clinic, Seoul, Republic of Korea
| | - David G. Hwang
- Cornea Service and Refractive Surgery Service, Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
| | - Sang Min Nam
- Department of Ophthalmology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
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Monteiro T, Alfonso JF, Freitas R, Franqueira N, Faria-Correira F, Ambrósio R, Madrid-Costa D. Comparison of Complication Rates between Manual and Femtosecond Laser-Assisted Techniques for Intrastromal Corneal Ring Segments Implantation in Keratoconus. Curr Eye Res 2019; 44:1291-1298. [PMID: 31226888 DOI: 10.1080/02713683.2019.1635165] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: To compare the incidence of complications between manual and femtosecond-laser assisted surgery for intrastromal corneal ring segments (ICRS) implantation.Material and methods: This study included keratoconus patients who had ICRS implantation using manual dissection and using the femtosecond laser with a minimum follow-up of 12 months. Uncorrected (UDVA) corrected (CDVA) distance visual acuity (CDVA), refraction, corneal topography and aberrometry, pachymetry map and slit-lamp microscopy were assessed before and after surgery.Results: The study included 265 eyes in the manual group and 111 in the femtosecond laser group. In the manual group, there were complications in 48 eyes (18.11%); while in the femtosecond laser 4 eyes had a complication (3.6%). In the manual group, the most frequent complications were ICRS exchange/adjustment for visual and refractive enhancement (25 eyes; 9.43%) and late ICRS spontaneous extrusion (15 eyes; 5.66%). In the manual group, 81.25% of complications were observed during the first 3 years of surgeon's experience. Eyes who suffered a complication had preoperatively higher mean refractive (p = .002) and topographic cylinder (p = .003) and lower UDVA (p = .005) and CDVA (p = .002). After a second surgical procedure for complication management visual, refractive and topographic outcomes significantly improved.Conclusion: Manual mechanical ICRS surgery shows a higher rate of intra- and postoperative mechanical and refractive complications when compared to femtosecond laser assisted technique. The incidence is specially higher during the surgeon's first years of implementation of the technique.
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Affiliation(s)
- Tiago Monteiro
- Ophthalmology Department, Hospital de Braga, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
| | - José F Alfonso
- Instituto Universitario Fernández-Vega, Fundación de Investigación Oftalmológica, Universidad de Oviedo, Oviedo, Spain
| | - Rui Freitas
- Ophthalmology Department, Hospital de Braga, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
| | - Nuno Franqueira
- Ophthalmology Department, Hospital de Braga, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
| | - Fernando Faria-Correira
- Ophthalmology Department, Hospital de Braga, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
| | - Renato Ambrósio
- Rio de Janeiro Corneal Tomography and Biomechanics Study Group, Rio de Janeiro, Brazil.,Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | - David Madrid-Costa
- Optometry and Vision Department, Faculty of Optics and Optometry, Universidad Complutense de Madrid, Madrid, Spain
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41
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Osipyan GA, Sheludchenko VM, Khraystin K. [Modern methods of surgical treatment of keratectasias]. Vestn Oftalmol 2019; 135:138-143. [PMID: 31215545 DOI: 10.17116/oftalma2019135021138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Keratectasia (KE) ranks as one of the main causes of impaired vision. The pathology is characterized by progressive thinning of the cornea, which causes its deformation, the appearance of irregular astigmatism, and the reduction of vision acuity. The article reviews modern surgical methods that can be used to prevent the progression and treat various types of KE.
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Affiliation(s)
- G A Osipyan
- Research Institute of Eye Diseases, 11, A, Rossolimo St., Moscow, Russian Federation, 119021
| | - V M Sheludchenko
- Research Institute of Eye Diseases, 11, A, Rossolimo St., Moscow, Russian Federation, 119021
| | - Kh Khraystin
- Research Institute of Eye Diseases, 11, A, Rossolimo St., Moscow, Russian Federation, 119021
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Sedaghat MR, Momeni-Moghaddam H, Piñero DP, Akbarzadeh R, Moshirfar M, Bamdad S, Gazanchian M. Predictors of Successful Outcome following Intrastromal Corneal Ring Segments Implantation. Curr Eye Res 2019; 44:707-715. [PMID: 30868919 DOI: 10.1080/02713683.2019.1594945] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Purpose: To assess the preoperative visual, refractive, corneal topo/tomographic, aberrometric and biomechanical parameters as predictive factors of a successful outcome 6 months following intrastromal corneal ring segments implantation. Methods: Sixty-eight keratoconus eyes implanted with Keraring using femtosecond laser technology were assessed. The preoperative assessed parameters included uncorrected and corrected distance visual acuity (UDVA & CDVA), refraction, placido-disk based topography using TMS-4, Scheimplfug tomography using Pentacam HR, corneal biomechanical assessments using Ocular Response Analyzer (ORA) and the wavefront analysis using i-Trace aberrometer. Other variables were type of astigmatism based on orientation of the steep meridian, keratoconus staging based on the Amsler-Krumeich classification and the difference between the axes of refractive astigmatism, topographic astigmatism and comatic aberration based on a difference less or more than 30°. The success criterion was defined based on CDVA, a post-operative CDVA improvement at least two lines were considered as a success and otherwise were recognized as a failure following Keraring implantation. Results: Only UDVA, coincidence of the most elevated points on the front and back corneal surfaces and the difference between UDVA and CDVA showed significant difference between the eyes with successful outcomes and those with unsuccessful results (P < 0.05). Although corneal curvature and astigmatism were higher and corneal thickness was lower in the unsuccessful group, differences were not statistically significant. Conclusion: It is expected that the greater difference between the preoperative uncorrected and corrected distance visual acuity (Δ UDVA-CDVA) and more coincidence of the most elevated points in the two corneal surfaces on the elevation maps increase the rate of successful outcome following the Keraring implantation. Abbreviations: ICRS: intrastromal corneal ring segments; UDVA: uncorrected distance visual acuity; CDVA: corrected distance visual acuity; logMAR: logarithm of minimum angle of resolution; SE: spherical equivalent; IOP: intra-ocular pressure; Km: mean keratometry; CA: corneal astigmatism; WTR: with-the-rule; ATR: against-the-rule; OBL: oblique; SB: symmetric bow-tie; AB: asymmetric bow-tie; IS: inferior steepening; SRAX: skewed radial axis; Q: asphericity (Q-value); CCT: central corneal thickness; CTP: corneal thinnest point; ORA: ocular response analyzer; CH: corneal hysteresis; CRF: corneal resistance factor; HOAs: higher-orders aberrations; RMS: root mean square; SD: standard deviation; CI: confidence interval.
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Affiliation(s)
| | - Hamed Momeni-Moghaddam
- b Health Promotion Research Center , Zahedan University of Medical Sciences , Zahedan , Iran.,c Department of Optometry, School of Paramedical Sciences , Mashhad University of Medical Sciences , Mashhad , Iran
| | - David P Piñero
- d Department of Optics, Pharmacology and Anatomy , University of Alicante , Alicante , Spain
| | - Reyhaneh Akbarzadeh
- c Department of Optometry, School of Paramedical Sciences , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Majid Moshirfar
- e John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, School of Medicine , University of Utah , Salt Lake City , UT , USA.,f Utah Lions Eye Bank, University of Utah Health , Murray , UT , USA.,g HDR Research Center, Hoopes Vision , Draper , UT , USA
| | - Shahram Bamdad
- h Poostchi Ophthalmology Research Center , Shiraz University of Medical Sciences , Shiraz , Iran
| | - Mehrdad Gazanchian
- a Eye Research Center , Mashhad University of Medical Sciences , Mashhad , Iran
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Izquierdo L, Mannis MJ, Mejías Smith JA, Henriquez MA. Effectiveness of Intrastromal Corneal Ring Implantation in the Treatment of Adult Patients With Keratoconus: A Systematic Review. J Refract Surg 2019; 35:191-200. [DOI: 10.3928/1081597x-20190109-02] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 01/07/2019] [Indexed: 11/20/2022]
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44
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Yip H, Chan E. Optical coherence tomography imaging in keratoconus. Clin Exp Optom 2019; 102:218-223. [PMID: 30793800 DOI: 10.1111/cxo.12874] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 12/23/2018] [Accepted: 01/01/2019] [Indexed: 11/28/2022] Open
Abstract
Optical coherence tomography (OCT) is being increasingly used as a tool in the diagnosis and management of keratoconus. While elevation-based topography remains essential, there is an expanding role for cross-sectional OCT imaging in the diagnosis of the disease. Images and measurements of corneal thickness, and in particular, epithelial thickness, may be important in diagnosing early cases, and following procedures such as intrastromal corneal ring segments, corneal transplants and corneal collagen cross-linking.
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Affiliation(s)
- Harry Yip
- School of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Elsie Chan
- Ophthalmology, Royal Victorian Eye and Ear Hospital, Centre for Eye Research Australia, The University of Melbourne, Melbourne, Victoria, Australia
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45
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Vastardis I, Thabit A, Elalfy M, Hamada S, Gatzioufas Z. Unexpected visual improvement after aborted intracorneal ring segment implantation for keratoconus. Ther Adv Ophthalmol 2019; 11:2515841418817500. [PMID: 30729232 PMCID: PMC6350120 DOI: 10.1177/2515841418817500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 10/31/2018] [Indexed: 11/16/2022] Open
Abstract
Purpose: To present a case of a complicated intracorneal ring segment (ICRS)
implantation procedure in a patient with keratoconus, who experienced
significant visual improvement, although the ICRS implantation had to be
aborted. Methods: A 25-year-old female patient with keratoconus underwent femtosecond
laser-assisted ICRS implantation in her right eye (OD) for improving visual
acuity. Results: The procedure had to be aborted, because ICRS implantation was not possible.
Anterior segment imaging 1 month after the procedure showed full-thickness
corneal incision with corneal microperforation. However, patient’s visual
acuity improved significantly due to amelioration of the keratometric
findings. Keratometric and visual improvement was preserved at 6 months
postoperatively. Conclusion: Our case report shows that femtosecond laser-assisted full-thickness corneal
incision on the astigmatic axis combined with the intracorneal tunnel
creation resulted unexpectedly in keratometric and visual improvement in
this keratoconus patient, even without the implantation of the ICRS.
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Affiliation(s)
| | - Ahmed Thabit
- Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| | - Mohamed Elalfy
- Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| | - Samer Hamada
- Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| | - Zisis Gatzioufas
- Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
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Nguyen N, Gelles JD, Greenstein SA, Hersh PS. Incidence and associations of intracorneal ring segment explantation. J Cataract Refract Surg 2019; 45:153-158. [DOI: 10.1016/j.jcrs.2018.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 09/07/2018] [Accepted: 09/24/2018] [Indexed: 10/27/2022]
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Garcia-Ferrer FJ, Akpek EK, Amescua G, Farid M, Lin A, Rhee MK, Varu DM, Musch DC, Mah FS, Dunn SP. Corneal Ectasia Preferred Practice Pattern®. Ophthalmology 2019; 126:P170-P215. [DOI: 10.1016/j.ophtha.2018.10.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 02/07/2023] Open
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Mounir A, Radwan G, Farouk MM, Mostafa EM. Femtosecond-assisted intracorneal ring segment complications in keratoconus: from novelty to expertise. Clin Ophthalmol 2018; 12:957-964. [PMID: 29872254 PMCID: PMC5973306 DOI: 10.2147/opth.s166538] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives To document the difference between complication rate in the early curve of practicing intracorneal stromal rings and after gaining experience. Patients and methods A retrospective study of 623 eyes of 417 patients with keratoconus who underwent Keraring implantation using femtosecond laser for channel creation. Results The main outcome measures were reported intraoperative and postoperative complications. The overall complication rate was 12.7% (79 eyes) over the 4 years with 34 eyes in the first year (5.5%) and six eyes in the fourth year (0.96%). Over the 4 years of our practice, intraoperative complications were 7.1% and postoperative complications were 5.6%. Yet, there was a significant difference in intraoperative complications between the first and the fourth year where it was 3.5% and 0.48%, respectively. This also applies to the postoperative complication rate, which decreased from 1.9% to 0.5% in the fourth year. Conclusion Complications with femtosecond-assisted intracorneal stromal ring procedure can be reduced by experience, making this procedure a safe and effective means of treating keratoconus. Yet, there are some complications that cannot be avoided such as sterile keratitis.
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Affiliation(s)
- Amr Mounir
- Department of Ophthalmology, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Gamal Radwan
- Department of Ophthalmology, Faculty of Medicine, Sohag University, Sohag, Egypt
| | | | - Engy Mohamed Mostafa
- Department of Ophthalmology, Faculty of Medicine, Sohag University, Sohag, Egypt
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Jacob S, Patel SR, Agarwal A, Ramalingam A, Saijimol AI, Raj JM. Corneal Allogenic Intrastromal Ring Segments (CAIRS) Combined With Corneal Cross-linking for Keratoconus. J Refract Surg 2018; 34:296-303. [PMID: 29738584 DOI: 10.3928/1081597x-20180223-01] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/22/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe a new technique for the treatment of keratoconus using corneal allogenic intrastromal ring segments (CAIRS). METHODS CAIRS trephined from donor cornea using a double-bladed trephine were implanted into mid-depth femtosecond laser-dissected channels in the cornea of patients with keratoconus in the 6.5-mm optic zone, followed by accelerated corneal cross-linking (A-CXL)-either conventional or contact lens-assisted CXL (A-CACXL), depending on minimum corneal thickness. RESULTS Twenty patients (24 eyes) with stage 1 to 4 keratoconus (Amsler-Krumeich grading) were included. Mean follow-up was 11.58 ± 3.6 months (range: 6 to 18 months). There was significant improvement in uncorrected (2.79 ± 2.65 lines; range: 0 to 8 lines) and corrected (1.29 ± 1.33 lines; range: 0 to 5 lines) distance visual acuity, spherical equivalent, simulated maximum keratometry, steepest keratometry, topographic astigmatism, anterior and posterior best fit spheres, and mean power in the 3- and 5-mm zones. No eye showed progression during the entire follow-up. All segments remained well positioned and no segment-induced complications were seen. No other major intraoperative or postoperative complications were observed. CONCLUSIONS This pilot study indicates that CAIRS with CXL may be a simple, safe, and effective option for treating keratoconus. Further studies are recommended to determine long-term outcomes. [J Refract Surg. 2018;34(5):296-303.].
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50
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Monteiro T, Alfonso JF, Franqueira N, Faria-Correia F, Ambrósio R, Madrid-Costa D. Predictability of Tunnel Depth for Intrastromal Corneal Ring Segments Implantation Between Manual and Femtosecond Laser Techniques. J Refract Surg 2018. [DOI: 10.3928/1081597x-20180108-01] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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